Information Collection

Medicaid Stgatisical Information System

IC 7979 under ICR 200303-0938-014 · OMB 0938-0345.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0345 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Medicaid Stgatisical Information System	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-0284				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	212	0	0	212
Annual IC Time Burden (Hours)	7,420	5,300	0	2,120
Annual IC Cost Burden (Dollars)	185,000	132,000	8,000	45,000

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.